Presentation on theme: "Infant Feeding: Human Milk and Formula Joan C Zerzan MS RD CD"— Presentation transcript:
1Infant Feeding: Human Milk and Formula Joan C Zerzan MS RD CD
2Feeding Recommendations ConsiderationsGrowth in infancyPhysiology of infancyGIRenalInfant DevelopmentNutrient requirementsProgrammingHealth and prevention
3Feeding Recommendations Nutrient needsProgrammingHealth, development, and prevention
4Considerations Coordinated sucking and swallowing Gastric emptying Intestinal motilitySecretions: salivary, gastric, pancreatic, hepatobiliaryEnterocyte function in terms of enzyme synthesis, absorption, mucosal protectionMetabolism of products of digestion and absorptionExpulsion of undigested waste products
6In uteroFetal GI tract is exposed to constant passage of fluid that contains a range of physiologically active factors:growth factorshormonesenzymesimmunoglobulinsThese play a role in mucosal differentiation and GI development as well as development of swallowing and intestinal motility
7At BirthGut of the newborn is faced with the formidable task of passing, digesting, and absorbing large quantities of intermittent boluses of milkComparable feeds per body weight for adults would be 15 to 20 L
8Gut HormonesGastrointestinal peptides are found in venous cord blood at birth in levels similar to those of fasting adultsIn fetal distress a number of gut peptides are elevated which might account for passage of meconiumWith enteral feeding levels of gut hormones (motilin, neurotensin, GIP (gastric inhibitory peptide), gastrin, enteroglucagon, PP - pancreatic polypeptide, rise rapidly
9Gut Hormones Influenced By: Choice of breast or formula feedsEnteric intake (induces epithelia hyperplasia and stimulates production of microvillous enzymes)Early enteral feeding (enteral feeding is strongly encouraged to promote GI function and differentiation)
10Possible Roles for Gut Hormones in Early Infancy
11PancreasPancreatic function is relatively deficient at birth and mature levels of pancreatic enzymes are not achieved until late infancyPancreatic amylase activity increases after 4 to 6 months Lipase levels do not approach adult efficiency until about 6 months
15Motility - Upper GI Esophageal motility is decreased in the newborn LES is primarily above the diaphragmLES pressure is less for first monthsGastric Emptying may be delayed
16Motility - Intestinal Intestinal motility is more disorganized Prolonged transit time in upper intestines may improve absorption of nutrientsRapid emptying of ileum and colon may reduce time for water and electrolyte absorption and increase risk of dehydration
17Maturation in First Year LES tone increases after 6 months and is associated with less reflux in most infantsGastric acid and pepsin activity do not reach adult levels until 2 yearsPancreatic amylase increases by 6 monthsRetention of lactase activity is typical until 3 to 5 years.Fat absorption does not approach adult efficiency until about 6 monthsLipase reaches adult levels by 2 years.
18RenalLimited ability to concentrate urine in first year due to immaturities of nephron and pituitaryPotential Renal solute load determined by nitrogenous end products of protein metabolism, sodium, potassium, phosphorus, and chloride.
20Renal solute load Samuel Foman J Pediatrics Jan 1999 134 # 1 (11-14) RSL is important consideration in maintaining water balance:In acute febrile illnessFeeding energy dense formulasAltered renal concentrating abilityLimited fluid intake
21RSL Water balance RSL in diet Water in Water out Renal concentrating ability
22Urine ConcentrationsMost normal adults are able to achieve urine concentrations of 1300 to 1400 mOsm/lHealthy newborns may be able to concentrate to mOsm/l, but isotonic urine of mOsm/l is the goalIn most cases this is not a concern, but may become one if infant has fever, high environmental temperatures, or diarrhea
23Programming by Early Diet Nutrient composition in early diet may have long term effects on GI function and metabolismAnimal models show that glucose and amino acid transport activities are programmed by composition of early dietAnimals weaned onto high CHO diet have higher rates of glucose absorption as adults compared to those weaned on high protein diet
24Allergies: Areas of Recent Interest Early introduction of dietary allergens and atopic responseatopy is allergic reaction/especially associated with IgE antibodyexamples: atopic dermatitis (eczema), recurrent wheezing, food allergy, urticaria (hives) , rhinitisPrevention of adverse reactions in high risk children
25Allergies: InfancyIncreased risk of sensitization as antigens penetrate mucosa, react with antibodies or cells, provoking cellular response and release of mediatorsImmaturities that increase risk:gastric acid, enzymesmicrovillus membraneslysosomal functions of mucosal cellsimmune system, less sIgA in lumen
26Allergies: IDDMTheory: sensitization and development of immune memory to food allergens may contribute to pathogenesis of IDDM in genetically susceptible individuals.Milk, wheat, soy have been implicated.Breastfeeding and delay in non-milk feedings may be beneficial.“There is little firm evidence of the significance of nutritional factors in the etiology of type 1 diabetes.” (Virtanen SM, Knip M. Am J Clin Nutr , 2003)
27Feeding the Infant Choices: Human Milk Standard Infant Formula (Cow, Soy)Hypoallergenic (hydrolysates vs amino acid basedOther specialty formulasPretermPost discharge formulas for preterm infants
28Infant Feeding: Historical Perspective Breast feedingHuman Milk SubstitutesScience, Medicine and Industry
29“No two hemispheres of any learned professor’s brain are equal to two healthy mammary glands in the production of a satisfactory food for infants”- Oliver Wendell Holmes
30Human Milk Complements Immaturities of these systems Promotes maturationEpithelial growth factors and hormonesDigestive enzymes - lipases and amylase
31Characteristics and Advantages of Human Milk Low renal solute loadImmunologic, growth and trophic factorsDecrease illness, infection, allergyImproved digestion and absorptionNutrient Composition: CHO, Protein, Fatty Acid, etcCostOther
32Breast milkNutrient composition of breastmilk is remarkable for its variability, as the content of some of the nutrients change during lactation, throughout the bay, or differ among women, while the content of some nutrients remain relatively constant throughout lactation.
33Human Milk Colostrum Higher concentration of protein and antibodies Transitions around days 3-5Mature by day 10
34Breastmilk and establishment of core microbiome Definition: Full collection of microbes that naturally exist within the body.Alterations or disruptions in core microbiome associated with chronic illness: Crohns disease, increased susceptability to infection, allergy, NEC, etc
35Microbiome Beneficial effect for the host: Nutrient metabolism Tissue developmentResistance to colonization with pathogensMaintenance of intestinal homeostasisImmunological activation and protection of GI integrity
36Human milk and microbiome Core microbiome established soon after birthCore microbiome of breastfeeding infant similar to core microbiome of lactating motherComponents of breastmilk supporting establishment of microbiomePrebiotics,probiotics
37AAP: Breast milk and allergy 1.Breast milk is an optimal source of nutrition for infants through the first year of life or longer. Those breastfeeding infants who develop symptoms of food allergy may benefit from:a.maternal restriction of cow's milk, egg, fish, peanuts and tree nuts and if this is unsuccessful,b.use of a hypoallergenic (extensively hydrolyzed or if allergic symptoms persist, a free amino acid-based formula) as an alternative to breastfeeding.
38Protein:Predominant protein of human milk is whey & predominant protein in cow’s milk is caseinCasein: proteins of the curd (low solubility at pH 4.6)Whey: soluble proteins (remain soluble at pH 4.6)Ratio of casein to whey is between 40:60 and 30:70 in human milk and 82:18 in cow’s milksome formulas provide more whey proteins than others
40Allergies: Breastmilk May be protective due to sIgA and mucosal growth factorsMaternal avoidance diets in lactation remain speculative. May be useful for some highly motivated families with attention to maternal nutrient adequacy.
41AAP: Breastfeeding and the Use of Human Milk, 1997 “Exclusive breastfeeding is ideal nutrition and sufficient to support optimal growth and development for approximately the first 6 months after birth….It is recommended that breastfeeding continue for at least 12 months, and thereafter for as long as mutually desired.”
42AAP: Breastfeeding and the Use of Human Milk, 1997 Human milk is the preferred feeding for all infantsBreastfeeding should begin as soon as possible after birthNewborns should be nursed 8 to 12 times every 24 hours until satiety, usually 10 to 15 minutes per breast. (Crying is a late indicator of hunger.)
43AAP: Breastfeeding and the Use of Human Milk, 1997 Formal evaluation of breastfeeding by trained observers at hours and again at 48 to 72 hours.No supplements should be given unless a medical indication exists.When discharged at <48 hours, should have FU visit at 2 to 4 days of age, assessment at 5 to 7 days, and be seen at one month.
44AAP: Breastfeeding and the Use of Human Milk, 1997 “Should hospitalization of the breastfeeding mother or infant be necessary, every effort should be made to maintain breastfeeding preferably directly or by pumping the breasts.”
45AAP statement on breastfeeding (continued) Supplements (water, glucose, formula) should be avoided (unless medically necessary). Pacifiers should also be avoided.Exclusive breastfeeding is ideal for the first 6 months. Breastfeeding should continue for at least 12 months.
46AAP statement on breastfeeding (continued) In the first 6 months, water, juice and other foods are generally unnecessary. Vitamin D and iron may be needed. Fluoride should not be given during the first 6 months.
47a.Breastfeeding mothers should continue breastfeeding for the first year of life or longer. During this time, for infants at risk, hypoallergenic formulas can be used to supplement breastfeeding. Mothers should eliminate peanuts and tree nuts (eg, almonds, walnuts, etc) and consider eliminating eggs, cow's milk, fish, and perhaps other foods from their diets while nursing. Solid foods should not be introduced into the diet of high-risk infants until 6 months of age, with dairy products delayed until 1 year, eggs until 2 years, and peanuts, nuts, and fish until 3 years of age.
48Formula Human Milk Substitutes History Regulation Composition and indications
49Formula Composition Breast Milk as “gold standard” Attempt to duplicate composition of breast milk? Bioactivity, relationship, function of all factors present in breast milk? Measure outcome: growth, composition, functional indicesExamples: DHA/ARA, Prebiotics and ProbioticsEvaluation: growth, composition, functional indices, other measures of safety and efficacy
50Formulas containing hydrolysed protein for prevention of allergy and food intolerance in infants (2006)There is no evidence to support feeding with a hydrolysed formula for the prevention of allergy compared to exclusive breast feeding. In high risk infants who are unable to be completely breast fed, there is limited evidence that prolonged feeding with a hydrolysed formula compared to a cow's milk formula reduces infant and childhood allergy and infant cow’s milk allergy. In view of methodological concerns and inconsistency of findings, further large, well designed trials comparing formulas containing partially hydrolysed whey, or extensively hydrolysed casein to cow's milk formulas are needed.
51Human Milk Substitutes Early evidence of artificial feedingMajority of infants received breast milkMaternal BFWet nursesWealthy womenOrphans, abandoned, “illegitimate”Prematurity or congenital deformities
52Human Milk Substitutes Wet nursesOther mammalian milk (cow, goat, donkey, camel)Pablum: bread/flour, mixed with water“bread, water, flour, sugar and castille soap to aid digestion”
53Human Milk Substitutes 1915 Gerstenberger developed first “complete infant formula” marketed as SMA (synthetic milk adapted)Base was defatted and diluted cow’s milk with beef tallow added to mimic the fat content of human milk
54Human Milk Substitutes ’s: evaporated or fresh cow’s milk, water and added CHO (prepared at home)1950’s to present commercially prepared infant formulas have replaced home recipes
55Science, Medicine, and Industry Infant Morbidity and MortalityRecognition of association with human milk substitutes, and infectionIndustrial developmentStorageSafetyFood industry
56Science, Medicine, and Industry Growth of child Health and welfare in early 20th century
57Historical timeline 1900 Pasteurization of milk in US Association between bacteria and diarrhea1912U.S Children’s BureauPublic Health and Pediatricians efforts to improve infant/child health and decrease mortality1920Intro evaporated milkCod liver oil prevents ricketsCurd tension of milk alteredIncreased availability of refrigerationVitamin C isolatedVitamin D prepared in pure formImproved sanitation
58Historical timeline 1940 1960 Homogenized milk widely marketed Further advances in technology and packagingCommercially prepared infant formula becoming increasingly popular
59Infant Formulas - History Cow’s milk is high in protein, low in CHO, results in large initial curd formation in gut if not heated before feedingEarly Formulasfrom majority of non-breastfed infants received evaporated milk formulas boiled or evaporated milk solved curd formation problemscho provided by corn syrup or other cho to decrease relative protein kcals
60Soy Formulas First developed in 1930s with soy flour Early formulas produced diarrhea and excessive gasNow use soy protein isolate with added methionine
61Infant Formula - History, cont. 50s and 60s commercial formulas replaced home preparation1959: iron fortification introduced, but in 1971 only 25% of infants were fed Fe fortified formulaCow’s milk feedings started in middle of first year between s. In 1970 almost 70% of infants were receiving cow’s milk.
62Regulation of Infant Formula FDAInfant Formula ActManufacturersVoluntary monitoringAAP, National Academy of Sciences, other professional organizationsGuidelines for composition and intake: (e.g. DRI’s)Guidelines for preparation and handling of formula/human milk in health care facilities
63Regulation of Infant Formulas Infant Formula Act: The purpose of the infant formula act (1980) is to ensure the safety and nutrition of infant formulas – including minimum and in some cases maximum levels of specified nutrients. The act authorizes the FDA to establish appropriate regulations for 1) new formulas, 2) formulas entering the U.S. market, 3) major changes, revisions, or substitutions of macronutrients 4) formulas manufactured in new plants or processing lines, 5) addition of new constituents 6) use of new equipment or technology 7) packaging changes
64Formula RegulationRegulation is by the Infant Formula Act of 1980, under FDA authorityNutrient composition guidelines for 29 nutrients established by AAP Committee on Nutrition and adopted as regs by FDANutrient Requirements for Infant Formulas. Federal Register 36, CFR Part 107.
65Regulation of Infant Formulas Infant Formula Act:Manufacturing regulationsQuality controlNon specific testing requirements, case by case basis, growth outcomesRecall ProceduresNutrient content and labelingPanel convened 1998 and 2002 (recommended revisions including exemptions)
66Infant Formula ActInstitute of Medicine Food and Nutrition Board 3/2004“Although the federal regulatory processes for evaluating the safety of food ingredients have worked well for conventional substances, they were not designed to ensure the needs and vulnerabilities of infants and are insufficient to ensure the safety of new types of ingredients proposed for infant formulas
67Infant Formula Act“The current regulatory processed do not fully address the unique role of formula as a food source. Formula is the only infants’ food if they are not being breastfed. The processes used to regulate the safety of any new additions of formula should be tailored to these products distict role and the special needs and susceptibilities of infants”
68Infant Formula ActKey limitation: lack of explicit guideleines for determining when and what safety data is needed…..(GRAS)Clarification is crucial given the increasing number of bioactive peptides and enzymens generated from unconventional sources or new technologies
69Infant Formula Act: Points for discussion Addition of DHA and ARA to formulasAddition of prebiotics to formulaPresent in BMGRASVitamin/mineral content conforms to regulation? testing
70Standard Infant Formulas, Milk or Soy Based………..
71Cow’s Milk Based Formula Commercial formula designed to approximate nutrients provided in human milkSome nutrients added at higher levels due to less complete digestion and absorption
72Formula Brands Ross Mead Johnson Nestle Wyeth SHS Similac/Isomil/AlimentumMead JohnsonEnfamil/Prosobee/EnfacareNestleGood StartWyethGeneric in USA; Gold Brands; SMASHSNeoCate, DuoCal
73Milk Based Formulas Standard 0-12 months Similac with ironEnfamil with ironGood Start Essentials/Good Start SupremeWyeth GenericStandard 0-12 mos with DHA/ARASimilac Advance with ironEnfamil Lipil with ironGood Start Supreme DHA/ARAWyeth formulas
74Milk Based Formulas Characteristics Blend of Whey and Casein Proteins ( % total calories)Carbohydrate: lactoseFats: long chainMeet needs of healthy infant
75Protein, cont.whey proteins of human and cow’s milk are different and have different amino acid profiles.Major whey proteins of human milk at a lactalbumin (high levels of essential aa) , immunoglobulins, and lactoferrin( enhances iron transportation)Cow’s milk has low levels of these proteins and high levels of b lactoglobulinInfants appear to thrive equally well with either whey or casein predominant formulas.
76Cow’s Milk Based Formula: Fat & CHO Fat: butterfat of cow’s milk is replaced with vegetable fat sources to make the fatty acid profile of cow’s milk formulas more like those of human milk and to increase the proportion of essential fatty acidsCho: Lactose is the major carbohydrate in most cows’ milk based formulas.
77Infant Formulas: AAPCow’s milk based formula is recommended for the first 12 months if breast milk is not available
79Soy Formulas Protein: soy protein isolate with added methionine Fat: vegetables oilsCho: usually corn based products
80Soy Formulas Characteristics compared to Milk Based Higher protein (lower quality)Higher sodium, calcium, and phosphorusCarbohydrate: Corn syrup solids, sucrose, and/or maltodextrin; lactose freeFats: Long chainMeet needs of healthy infants
81Possible Concerns about Soy Formulas: AAP 60% of infants with cowmilk protein induced enterocolitis will also be sensitive to soy protein - damaged mucosa allows increased uptake of antigen.Contains phytates and fiber oligosacharides so will inhibit absorption of minerals (additional Ca is added)Higher levels of osteopenia in preterm infants given soy formulasPhytoestrogens at levels that demonstrate physiologic activity in rodent modelsHigher aluminum levels
82Health Consequences of Early Soy Consumption. Badger et al. J Nutr US soy formulas made with soy protein isolate (SPI+)SPI+ has several phytochemicals, including isoflavonesIsoflavones are referred to as phytoestrogensPhytoestrogens bind to estrogen receptors & act as estrogen agonists, antagonists, or selective estrogen receptor modulators depending on tissue, cell type, hormonal status, age, etc.
83Figure 1. Hypothetical serum concentrations profile of isoflavones from conception through weaning in typical Asians and Americans. The values represent the range of isoflavonoids reported by Adlercreutz et al. (6 ) for Japanese (dotted lines) or reported by Setchell et al. (3 ) for Americans fed soy infant formula (dashed line).
84Should we be Concerned? - Badger et al. No human data support toxicity of soyfoodsSoyfoods have a long history in AsiaMillions of American infants have been fed soy formula over the past 3 decadesRat studies indicate a potential protective effect of soy in infancy for cancer
85Soy formulas given to 25% of infants but needed by very few American Academy of Pediatrics Committee on Nutrition. Soy Protein-based Formulas: Recommendations for Use in Infant Feeding. Pediatrics 1998;101:Soy formulas given to 25% of infants but needed by very fewOffers no advantage over cow milk protein based formula as a supplement for breastfed infantsProvides appropriate nutrition for normal growth and developmentIndicated primarily in the case of vegetarian families and for the very small number of infants with galactosemia and hereditary lactase deficiency
86Contraindications to Soy Formula: AAP preterm infants due to increased risk of inadequate bone mineralizationinfants with cow milk protein-induced enteropathy or enterocolitismost previously well infants with acute gastroenteritisprevention of colic or allergy.
87Soy formula for prevention of allergy and food intolerance in infants (Cochrane, 2006) “Feeding with a soy formula cannot be recommended for prevention of allergy or food intolerance in infants at high risk of allergy or food intolerance. Further research may be warranted to determine the role of soy formulas for prevention of allergy or food intolerance in infants unable to be breast fed with a strong family history of allergy or cow's milk protein intolerance.”
88Those infants with IgE-associated symptoms of allergy may benefit from a soy formula, either as the initial treatment or instituted after 6 months of age after the use of a hypoallergenic formula. The prevalence of concomitant is not as great between soy and cow's milk in these infants compared with those with non–IgE-associated syndromes such as enterocolitis, proctocolitis, malabsorption syndrome, or esophagitis. Benefits should be seen within 2 to 4 weeks and the formula continued until the infant is 1 year of age or older.
89Breast-milk should remain the feed of choice for all babies. Cow’s milk protein avoidance and development of childhood wheeze in children with a family history of atopy (Cochrane, 2003)Breast-milk should remain the feed of choice for all babies.In infants with at least one first degree relative with atopy, hydrolysed formula for a minimum of four months combined with dietary restrictions and environment measures may reduce the risk of developing asthma or wheeze in the first year of life.There is insufficient evidence to suggest that soya-based milk formula has any benefit.
91Protein Hydrolysate Formulas Alimentum AdvancePregestimil/Pregestimil LipilNutramigen LipilProtein Casein hyrolysate + free AA’sFat (Alimentum and Pregestimil) Medium chain + Long chain triglycerides; (Nutramigen) Long chain triglyceridesCarbohydrate: Lactose free
92Hydrolysate FormulasWhey Hydrolysate Formula: Cow’s milk based formula in which the protein is provided as whey proteins that have been hydrolyzed to smaller protein fractions, primarily peptides. This formula may provoke an allergic response in infants with cow’s milk protein allergy.Casein Hydrolysate Formula: Infant formula based on hydrolyzed casein protein, produced by partially breaking down the casein into smaller peptide fragments and amino acids. `
94AAP: Breast milk and allergy 1.Breast milk is an optimal source of nutrition for infants through the first year of life or longer. Those breastfeeding infants who develop symptoms of food allergy may benefit from:a.maternal restriction of cow's milk, egg, fish, peanuts and tree nuts and if this is unsuccessful,b.use of a hypoallergenic (extensively hydrolyzed or if allergic symptoms persist, a free amino acid-based formula) as an alternative to breastfeeding.
952.Formula-fed infants with confirmed cow's milk allergy may benefit from the use of a hypoallergenic or soy formula as described for the breastfed infant.
963.Infants at high risk for developing allergy, identified by a strong (biparental; parent, and sibling) family history of allergy may benefit from exclusive breastfeeding or a hypoallergenic formula or possibly a partial hydrolysate formula. Conclusive studies are not yet available to permit definitive recommendations. However, the following recommendations seem reasonable at this time:
97AAP Policy Statement Re: Hypoallergenic Infant Formulas (August, 2000) Currently available, partially hydrolyzed formulas are not hypoallergenic.
98AAP Policy Statement Re: Hypoallergenic Infant Formulas (August, 2000) Carefully conducted randomized controlled studies in infants from families with a history of allergy must be performed to support a formula claim for allergy prevention. Allergic responses must be established prospectively, evaluated with validated scoring systems, and confirmed by double-blind,placebo-controlled challenge. These studies should continue for at least 18 months and preferably for 60 to 72 months or longer where possible
99Formulas containing hydrolysed protein for prevention of allergy and food intolerance in infants (2006)There is no evidence to support feeding with a hydrolysed formula for the prevention of allergy compared to exclusive breast feeding. In high risk infants who are unable to be completely breast fed, there is limited evidence that prolonged feeding with a hydrolysed formula compared to a cow's milk formula reduces infant and childhood allergy and infant cow’s milk allergy. In view of methodological concerns and inconsistency of findings, further large, well designed trials comparing formulas containing partially hydrolysed whey, or extensively hydrolysed casein to cow's milk formulas are needed.
100Specialty Formulas Elemental - Neocate Premature Follow Up - Neosure, Enfamil 22Other highly specialized for metabolic conditions
102Elemental Infant Formula NeoCate (SHS)Protein: Free Amino AcidsFat: Long chainCarbohydrate: Lactose FreeIndications for use: Food Allergy or intolerance to peptides or whole protein
103Premature Infant Breast Milk Additives and Formulas Enfamil Human Milk FortifierSimilac Human Milk FortifierPowdered breast milk additivesSimilac Natural Care AdvanceLiquid breast milk additiveSimilac Special Care AdvanceEnfamil Premature +/- Lipil
104Premature Formulas General Characteristics compared to Standard Increased Protein,Vitamins & MineralsFor infants born at <1.5kgup to gmFeeding of infants > 2500 gmrisk of vitamin toxicitiesPremature formulas vary in nutrient content
106“Post” Premature Formulas NeoSure AdvanceEnfaCare LipilStandard Dilution: 22 kcal/ozProtein: between standard and PrematureVitamins: Higher than standard,significantly lower than PrematureCalcium and Phosphorus: between standard and Premature
107Other Specialty Formulas Portagen (Mead Johnson)85% fat MCT, 15% fat Corn oilUsed for infants with chylothoraxSimilac PM 60/40 (Ross)Low in Ca, P, K+ and NA; 2:1 Ca:P ratioUsed for infants with Renal FailureFormulas for Metabolic DisordersSeveral condition specific products by Ross and Mead Johnson
108Indications Cow’s milk based Soy Protein Hydrolysates Preterm Formulas Health term infantSoyVegetarianGalactosemiaProtein HydrolysatesProtein intolerance/allergyotherPreterm FormulasPost-discharge Preterm formulasOther Specialty FormulasSpecific medical, metabolic indications
109Know What You Are Feeding Caloric density, protein, fat and carbohydrate vitamin and mineral content.Osmolality:Renal Solute Load: Evaluate RSL in context of solute intake, fluid intake and output.Evidence BasedRationaleCost and availability
110Finding Up to Date Information Similac productsEnfamil productsNestle productsgeneric productslower cost formulas made by WyethNeocate formulas
115AAP: Cow’s Milk in Infancy Objections include:Cow’s milk poor source of ironGI blood loss may continue past 6 monthsBovine milk protein and Ca inhibit Fe absorptionIncreased risk of hypernatremic dehydration with illnessLimited essential fatty acids, vitamin C, zincExcessive protein intake with low fat milks
116Cows milk and goats milk ProteinRSLFolic acid, iron, vitamin Dpasteurization
117Formula Safety Issues - 2002 Enterobacter Sakazakii in Intensive care unitsPowered formula is not sterile so should not be used with high risk infantsFDA recommends mixing with boiling water but this may affect availability of vitamins & proteins and also cause clumpingIrradiation proposed
119Milk Feedings Cautionary Tales Cooper et al. Pediatrics Increased incidence of severe breastfeeding malnutrition and hypernatremia in a metropolitan area.Keating et al. AJDC Oral water intoxication in infants.Lucas et al. Arch Dis Child Randomized trial of ready to fed compared with powdered formula.
120Cooper, cont.5 breastfed infants admitted to Children’s hospital in Cincinnati over 5 months period for breastfeeding malnutrition and dehydrationage at readmission was 5 to 14 daysmothers were between the ages of 28 and 38, had prepared for breastfeeding3 had inverted nipples and reported latch-on problems before discharge3 families had contact with health care providers before readmission including calls to PCP and home visit by PHN
121Cooper, cont.at time of readmit none of presenting complaints related to s&s of dehydration, only one infant presented with feeding complaintwt. Loss at admission: 23%, range 14-32%Serum Na - mean 186 mmol/l, range ( is wnl)3 infants had severe complications: multiple cerebral infarctions, left leg amputation secondary to iliac artery thrombus
122Keating24 cases of oral water intoxication in 3 years at Children’s Hospital and St. LouisMost were from very low income families and were offered water at home when formula ran outAuthors suggest: provision of adequate formula and anticipatory guidance
123Lucas 43 infants randomized to RTF or powdered formula Infants given powdered formula had increased body wt. And skinfold thickness at 3 and 6 mos.. Compared to RTF and breastfedPowdered formula - 6 of 19 were above the 90th percentile wt/ht, but only 1 of 19 RTF infantsAuthors suggest errors in reconstitution of formula
124Formula Preparation Microwave Protocol (Sigman-Grant, 1992) Heat only 4 oz or more refrigerated formula with bottle top uncovered4 oz bottles < 30 seconds8 oz bottles < 45 secondsInvert 10 times before useShould be cool to the touchAlways test drops of formula on tongue or top of hand
125Bright Futures AAP/HRSA/MCHB http://www.brightfutures.org “Bright Futures is a practical development approach to providing health supervision for children of all ages from birth through adolescence.”
126Newborn Visit: Breastfeeding Infant Guidancehow to hold the baby and get him to latch on properly;feeding on cue 8-12 times a day for the first four to six weeks;feeding until the infant seems content.Newborn breastfed babies should have six to eight wet diapers per day, as well as several "mustardy" stools per day.Give the breastfeeding infant 400 I.U.'s of vitamin D daily if he is deeply pigmented or does not receive enough sunlight.
127Newborn Visit: Breastfeeding Maternal carerestfluidsrelieving breast engorgementcaring for nippleseating properlyFollow-up support from the health professional by telephone, home visit, nurse visit, or early office visit.
128Newborn Visit: Bottle-feeding type of formula, preparationfeeding techniques, and equipment.Hold baby in semi-sitting position to feed.Do not use a microwave oven to heat formula. To avoid developing a habit that will harm your infant's teeth, do not put him to bed with a bottle or prop it in his mouth.
129First WeekDo not give the infant honey until after her first birthday to prevent infant botulism.To avoid developing a habit that will harm your infant's teeth, do not put her to bed with a bottle or prop it in her mouth.
130One MonthDelay the introduction of solid foods until the infant is four to six months of age. Do not put cereal in a bottle.
131Four MonthsContinue to breastfeed or to use iron-fortified formula for the first year of the infant's life. This milk will continue to be his major source of nutrition.Begin introducing solid foods with a spoon when the infant is four to six months of age.Use a spoon to give him an iron-fortified, single-grain cereal such as rice.
132Four Months, cont.If there are no adverse reactions, add a new pureed food to the infant's diet each week, beginning with fruits and vegetables.Always supervise the infant while he is eating.Give exclusively breastfeeding infants iron supplements.Continue to give the breastfeeding infant 400 I.U.'s of vitamin D daily if he is deeply pigmented or does not receive enough sunlight.Do not give the infant honey until after his first birthday to prevent infant botulism. .
133Six Months, cont.Let the infant indicate when and how much she wants to eat.Serve solid food two or three times per day.Begin to offer a cup for water or juice.Limit juice to four to six ounces per day.Give iron supplements to infants who are exclusively breastfeeding.